Computed tomography analysis of sagittal plane parameters in adolescent idiopathic scoliosis treated by video assisted thoracoscopic spinal fusion and instrumentation

One of the primary treatment goals of adolescent idiopathic scoliosis (AIS) surgery is to achieve maximum coronal plane correction while maintaining coronal balance. However maintaining or restoring sagittal plane spinal curvature has become increasingly important in maintaining the long-term health of the spine. Patients with AIS are characterised by pre-operative thoracic hypokyphosis, and it is generally agreed that operative treatment of thoracic idiopathic scoliosis should aim to restore thoracic kyphosis to normal values while maintaining lumbar lordosis and good overall sagittal balance. The aim of this study was to evaluate CT sagittal plane parameters, with particular emphasis on thoracolumbar junctional alignment, in patients with AIS who underwent Video Assisted Thoracoscopic Spinal Fusion and Instrumentation (VATS). This study concluded that video-assisted thoracoscopic spinal fusion and instrumentation reliably increases thoracic kyphosis while preserving junctional alignment and lumbar lordosis in thoracic AIS.

Fusionless scoliosis correction using shape memory alloy staples

Severe spinal deformity in young children is a formidable challenge for optimal treatment. Standard interventions for adolescents, such as spinal deformity correction and fusion, may not be appropriate for young patients with considerable growth remaining. Alternative surgical options that provide deformity correction and protect the growth remaining in the spine are needed to treat this group of patients 1, 2. One such method is the use of shape memory alloy staples. We report our experience to date using video-assisted thoracoscopic insertion of shape memory alloy staples. A retrospective review was conducted of 13 patients with scoliosis, aged 7 to 13 years, who underwent video-assisted thoracoscopic insertion of shape memory staples. In our experience, video-assisted thoracoscopic insertion of shape memory alloy staples is a safe procedure with no complications noted. It is a reliable method of providing curve stability, however the follow up results to date indicate that the effectiveness of the procedure is greater in younger patients.

Design and evaluation of an MRI compatible axial compression device for 3D assessment of spinal deformity and flexibility

Magnetic Resonance Imaging (MRI) offers a valuable research tool for the assessment of 3D spinal deformity in AIS, however the horizontal patient position imposed by conventional scanners removes the axial compressive loading on the spine which is an important determinant of deformity shape and magnitude in standing scoliosis patients. The objective of this study was to design, construct and test an MRI compatible compression device for research into the effect of axial loading on spinal deformity using supine MRI scans. The compression device was designed and constructed, consisting of a vest worn by the patient, which was attached via straps to a pneumatically actuated footplate. An applied load of 0.5 x bodyweight was remotely controlled by a unit in the scanner operator’s console. The entire device was constructed using non-metallic components for MRI compatibility. The device was evaluated by performing unloaded and loaded supine MRI scans on a series of 10 AIS patients. The study concluded that an MRI compatible compression device had been successfully designed and constructed, providing a research tool for studies into the effect of axial loading on 3D spinal deformity in scoliosis. The 3D axially loaded MR imaging capability developed in this study will allow future research investigations of the effect of axial loading on spinal rotation, and for imaging the response of scoliotic spinal tissues to axial loading.

3D lung and rib cage reconstruction using low dose CT scans of adolescent idiopathic scoliosis pre and post anterior thoracoscopic correction

Adolescent Idiopathic Scoliosis (AIS) has been associated with reduced pulmonary function believed to be due to a restriction of lung volume by the deformed thoracic cavity. A recent study by our group examined the changes in lung volume pre and post anterior thoracoscopic scoliosis correction using pulmonary function testing (1), however the anatomical changes in ribcage shape and left/right lung volume after thoracoscopic surgery which govern overall respiratory capacity are unknown. The aim of this study was to use 3D rendering from CT scan data to compare lung and ribcage anatomical changes from pre to two years post thoracoscopic anterior scoliosis correction. The study concluded that 3D volumetric reconstruction from CT scans is a powerful means of evaluating changes in pulmonary and thoracic anatomy following surgical AIS correction. Most likely, lung volume changes following thoracoscopic scoliosis correction are multifactorial and affected by changes in height (due to residual growth), ribcage shape, diaphragm positioning, Cobb angle correction in the thoracic spine. Further analysis of the 3D reconstructions will be performed to assess how each of these factors affect lung volume in this patient cohort.

Development of a multi-scale finite element model of the osteoporotic lumbar vertebral body for the investigation of apparent level vertebra mechanics and micro-level trabecular mechanics.

Osteoporotic spinal fractures are a major concern in ageing Western societies. This study develops a multi-scale finite element (FE) model of the osteoporotic lumbar vertebral body to study the mechanics of vertebral compression fracture at both the apparent (whole vertebral body) and micro-structural (internal trabecular bone core)levels. Model predictions were verified against experimental data, and found to provide a reasonably good representation of the mechanics of the osteoporotic vertebral body. This novel modelling methodology will allow detailed investigation of how trabecular bone loss in osteoporosis affects vertebral stiffness and strength in the lumbar spine.

The effect of friction on indenter force and pile-up in numerical simulations of bone nanoindentation

Nanoindentation is a useful technique for probing the mechanical properties of bone, and finite element (FE) modeling of the indentation allows inverse determination of elasto-plastic constitutive properties. However, FE simulations to date have assumed frictionless contact between indenter and bone. The aim of this study was to explore the effect of friction in simulations of bone nanoindentation. Two dimensional axisymmetric FE simulations were performed using a spheroconical indenter of tip radius 0.6m and angle 90°. The coefficient of friction between indenter and bone was varied between 0.0 (frictionless) and 0.3. Isotropic linear elasticity was used in all simulations, with bone elastic modulus E=13.56GPa and Poisson’s ratio =0.3. Plasticity was incorporated using both Drucker-Prager and von Mises yield surfaces. Friction had a modest effect on the predicted force-indentation curve for both von Mises and Drucker-Prager plasticity, reducing maximum indenter displacement by 10% and 20% respectively as friction coefficient was increased from zero to 0.3 (at a maximum indenter force of 5mN). However, friction has a much greater effect on predicted pile-up after indentation, reducing predicted pile-up from 0.27m to 0.11m with a von Mises model, and from 0.09m to 0.02m with Drucker-Prager plasticity. We conclude that it is important to include friction in nanoindentation simulations of bone.

Design and evaluation of an MRI compatible axial compression device for 3D assessment of spinal deformity and flexibility in adolescent idiopathic scoliosis

Magnetic Resonance Imaging (MRI) offers a valuable research tool for the assessment of 3D spinal deformity in AIS, however the horizontal patient position imposed by conventional scanners removes the axial compressive loading on the spine. The objective of this study was to design, construct and test an MRI compatible compression device for research into the effect of axial loading on spinal deformity using supine MRI scans. The device was evaluated by performing unloaded and loaded supine MRI scans on a series of 10 AIS patients. The patient group had a mean initial (unloaded) major Cobb angle of 43±7º, which increased to 50±9º on application of the compressive load. The 7° increase in mean Cobb angle is consistent with that reported by a previous study comparing standing versus supine posture in scoliosis patients (Torell et al, 1985. Spine 10:425-7).

Distribution of forces during fulcrum bending radiographs on adolescent idiopathic scoliosis patients

At the Mater Children’s Hospital, approximately 80% of patients presenting with Adolescent Idiopathic Scoliosis requiring corrective surgery receive a fulcrum bending radiograph. The fulcrum bending radiograph provides a measurement of spine flexibility and a better indication of achievable surgical correction than lateral-bending radiographs (Cheung and Luk, 1997; Hay et al 2008). The magnitude and distribution of the corrective force exerted by the bolster on the patient’s body is unknown. The objective of this pilot study was to measure, for the first time, the forces transmitted to the patient’s ribs through the bolster during the fulcrum bending radiograph.

Development of patient-specific computer simulation tools for endoscopic scoliosis surgery

Endoscopic approaches for anterior correction of idiopathic scoliosis are a relatively new surgical technique. This paper describes the development of patient-specific finite element modelling techniques to investigate the biomechanics of single rod anterior scoliosis correction. Spinal geometry is obtained from pre-operative CT scans and material properties for osteo-ligamentous spinal tissues are based on existing literature. The techniques being developed will allow pre-surgical prediction of stresses, forces and deformations in spinal tissues, rods and screws under post-operative physiological loads.

The relationship between deformity correction and clinical outcomes after thoracoscopic scoliosis surgery : a prospective series of one hundred patients

Prospective clinical case series of 100 patients receiving thoracoscopic anterior scoliosis correction surgery. The objective was to evaluate the relationship between clinical outcomes of thoracoscopic anterior scoliosis surgery and deformity correction using the Scoliosis Research Society (SRS) outcomes instrument questionnaire. The surgical treatment of scoliosis is quantitatively assessed in the clinic using radiographic measures of deformity correction, as well as the rib hump, but it is important to understand the extent to which these quantitative measures correlate with self-reported improvements in patients’ quality of life following surgery. A series of 100 consecutive adolescent idiopathic scoliosis patients received a single anterior rod via a thoracoscopic approach at the Mater Children’s Hospital, Brisbane, Australia. Patients completed SRS outcomes questionnaires pre-operatively and at 24 months post-operatively. There were 94 females and 6 males with a mean age of 16.1 years. The mean Cobb angle improved from 52º pre-operatively to 25º post-operatively (52%) and the mean rib hump improved from 16º to 8º (51%). The mean total SRS score for the cohort was 99.4/120. None of the deformity related parameters in the multiple regression were significant. However, patients with the lowest post-operative major Cobb angles reported significantly higher SRS scores than those with the highest post-operative Cobb angles, but there was no difference on the basis of rib hump correction. There were no significant differences between patients with either rod fractures or screw-related complications compared to those without complications.

Re-imagining China's future : soft power, cultural presence and the East Asian media market

As various contributors to this volume suggest, the term soft power is multifaceted. In 2002 Joseph Nye, the political scientist who coined the term more than a decade previously, noted that the soft power of a country rests on three resources: a country’s culture, its political values, and its foreign policies (Nye 2002). However, several factors can be drawn together to explain China’s adoption of this concept. First, China’s economic influence has precipitated a groundswell of nationalism, which reached its apex at the Opening Ceremony of the 2008 Beijing Olympics. This global media event provided an international platform to demonstrate China’s new found self-confidence. Second, cultural diplomacy and foreign aid, particularly through Third World channels is seen by the Chinese Communist Party leadership as an appropriate way to extend Chinese influence globally (Kurlantzick 2007). Third, education in Chinese culture through globally dispersed Confucius Institutes is charged with improving international understanding of Chinese culture and values, and in the process renovating negative images of China. Fourth, the influence of Japanese and Korean popular culture on China’s youth cultures in recent years has caused acute discomfit to cultural nationalists. Many contend it is time to stem the tide. Fifth, the past few years have witnessed a series of lively debates about the importance of industries such as design, advertising, animation and fashion, resulting in the construction of hundreds of creative clusters, animation centres, film backlots, cultural precincts, design centres and artist lofts.

Adaptive modelling of sustainable architecture design in entropy evolutionary

This paper argues a model of adaptive design for sustainable architecture within a framework of entropy evolution. The spectrum of sustainable architecture consists of efficient use of energy and material resource in the life-cycle of buildings, active involvement of the occupants into micro-climate control within the building, and the natural environment as the physical context. The interactions amongst all the parameters compose a complex system of sustainable architecture design, of which the conventional linear and fragmented design technologies are insufficient to indicate holistic and ongoing environmental performance. The latest interpretation of the Second Law of Thermodynamics states a microscopic formulation of an entropy evolution of complex open systems. It provides a design framework for an adaptive system evolves for the optimization in open systems, this adaptive system evolves for the optimization of building environmental performance. The paper concludes that adaptive modelling in entropy evolution is a design alternative for sustainable architecture.

Preparation of porous calcium phosphate ceramic scaffold in bone tissue engineering

Calcium Phosphate ceramic has been widely used in bone tissue engineering due to its excellent biocompatibility and biodegradability. However, low mechanical properties and biodegradability limit their potential applications. In this project, hydroxyapatite (HA) and calcium phosphate bioglass were used to produce porous tri-calcium phosphate (TCP) bio-ceramic scaffolds. It was found that porous TCP bioceramic could be obtained when 20wt percent bioglass addition and sintered in 1400 degrees celsius for 3 h. Significantly higher compressive strength (9.98 MPa) was achieved in the scaffolds as compared to those produced from tCP power (<3 MPa). The biocompatibility of the scaffold was also estimated.

Preparation of mesoporous bioglass coated zirconia scaffold for bone tissue engineering

Porous yttria-stabilized zirconia (YSZ) has been regarded as a potential candidate for bone substitute due to its high mechanical strength. However, porous YSZ is biologically inert to bone tissue. It is therefore necessary to introduce bioactive coatings onto the walls of the porous structures to enhance its bioactivity. In this study, porous YSZ scaffolds were prepared using a replication technique and then coated with mesoporous bioglass due to its excellent bioactivity. The microstructures were examined using scanning electron microscopy and the mechanical strength was evaluated via compression test. The biocompatibility and bioactivity were also evaluated using bone marrow stromal cell (BMSC) proliferation test and simulated body fluid test.

Patient-specific computational biomechanics for simulating adolescent scoliosis surgery : predicted vs clinical correction for a preliminary series of six patients

Scoliosis is a spinal deformity that requires surgical correction in progressive cases. In order to optimize surgical outcomes, patient-specific finite element models are being developed by our group. In this paper, a single rod anterior correction procedure is simulated for a group of six scoliosis patients. For each patient, personalised model geometry was derived from low-dose CT scans, and clinically measured intra-operative corrective forces were applied. However, tissue material properties were not patient-specific, being derived from existing literature. Clinically, the patient group had a mean initial Cobb angle of 47.3 degrees, which was corrected to 17.5 degrees after surgery. The mean simulated post-operative Cobb angle for the group was 18.1 degrees. Although this represents good agreement between clinical and simulated corrections, the discrepancy between clinical and simulated Cobb angle for individual patients varied between -10.3 and +8.6 degrees, with only three of the six patients matching the clinical result to within accepted Cobb measurement error of +-5 degrees. The results of this study suggest that spinal tissue material properties play an important role in governing the correction obtained during surgery, and that patient-specific modelling approaches must address the question of how to prescribe patient-specific soft tissue properties for spine surgery simulation.